Provider Demographics
NPI:1104800051
Name:BLAND, MARY M (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:BLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-967-8622
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:1168 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2444
Practice Address - Country:US
Practice Address - Phone:757-686-3508
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18471207Q00000X
VA0101256886207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001737863OtherMS BCBS
WV3810000329Medicaid
WV3810000660Medicaid
WV3810000329Medicaid
WV2024851Medicare PIN
G64265Medicare UPIN